Definition.
Mental health services
research is both a basic and applied multidisciplinary field which explores
issues of access to care, utilization, cost, organization, financing,
delivery, quality of care, and outcomes of mental health care services. Its
purpose is to increase the knowledge and understanding of the structure,
processes, and effects of mental health services that are provided to
individuals and special populations.

What are the origins of mental health
services research?Mental health services research which evolved
from the social and behavioral sciences as well as from the field of psychiatric
epidemiology, draws from a large body of theoretical and empirical research in
these fields. It seeks to answer questions about basic individual,
organizational, and systemic behaviors as well as practical questions that
managers and policymakers may ask.

Prior to the 1950s, much of the research focused
on state-operated hospitals and the care provided within them. Early behavioral
science research that examined familial responses to mental illness and the
precipitating factors that lead to an individual's hospitalization is still
considered important to the field. The epidemiologic studies conducted prior to
the 1960s focused on issues such as how individuals entered treatment, how long
they remained in treatment once a referral was made, and the ways in which
individual characteristics interacted with the type of treatment provided and
the setting in which it occurred.

Between 1955 and 1975 the policy of deinstitutionalization
facilitated a change in the way mental health services were provided. Much of
the research conducted in the 1970s and early 1980s addressed two broad
empirical questions: 1) whether the services provided in the community could
effectively replace the services provided in the custodial hospital; and, 2)
whether the cost of community treatment was less than the cost of treatment in
the institution.

During the late 1970s and 1980s, as the focus
shifted more toward the cost, financing, and reimbursement of services,
economists entered the field of health services research. However, many
economists were still somewhat reluctant to enter the mental health services
research field because the definitions of mental illness were often unreliable
and the effectiveness of many of the treatments had not been demonstrated.
Currently, economic models and economic analyses are used increasingly to
examine the effects of financial incentives on providers, organizations, and
consumers of mental health services and the extent to which alternative methods
of organizing and providing services are efficient.

At this same time, clinical researchers in
psychology, social work, and psychiatry focused their efforts on systematically
defining and measuring the components of mental health and illness. Both
clinical drug trials and psychotherapy research expanded the knowledge base with
respect to the effectiveness of particular mental health interventions. In the
late 1980s and early 1990s, managed care became a predominant force in
the field and much of this work evolved into clinical outcomes research.

A final shift in the focus of mental health
services research involved vulnerable populations such as children, the elderly,
and individuals who suffer from both mental disorders and substance abuse
disorders (dual diagnoses). There are a growing number of studies that address
issues unique to these populations.

While the strength of the field is that it
requires a multidisciplinary approach to mental health and illness, adopting
such an approach to scientific inquiry is problematic. Traditional disciplinary
boundaries, competing theoretical and methodological approaches, and even the
terminology employed by the various disciplines often present impediments to
truly collaborative research. In an attempt to overcome these barriers,
interdisciplinary programs in services research evolved within academic
institutions, private sector research organizations and units, and funding
agencies.

Who are the professionals that provide mental
health services?Mental health services are provided both in formal psychiatric and health care
organizations as well as in office-based practice settings by a variety of
professionals including psychiatrists, clinical psychologists, clinical social
workers, marriage and family therapists, psychiatric nurses, and mental health
counselors.

Mental health services researchers have examined
the relationships among skills, financing patterns, and treatment utilization.
Early studies indicated that total hospitalization days among patients of
psychiatrists were higher but that these patients were more impaired on several
health status measures. On the other hand, psychologists' clients seemed to
average a higher number of visits when compared to those of psychiatrists.
Service patterns of the other professionals were not included.

In addition to these professionals, primary care
clinicians have become an important part of the mental health services delivery
system. These types of clinicians, e.g., office-based physicians and associated
health providers in general internal medicine, general pediatrics, family
practice, are often the primary source of health care of any kind for many
individuals who suffer from mental disorders.

The existing research points to several findings
that should be explored to a greater degree in the future. In general, primary
care clinicians provide services to a large number of individuals, however,
these clinicians generally under-recognize, under-diagnose and under-treat
clients with mental disorders. Although interventions to alter the current
situation have been made, further research is required to determine if these
interventions would change mental health service delivery in primary care. The
literature on mental health services that are provided in primary care settings
is generally descriptive in nature and focuses on the process or clinical
aspects of care; it has not generally examined the organizational and financial
factors that affect service delivery.

In what type of settings are services
provided? A vast array of organizations, both in the private sector and public sector,
provide mental health services. The organizations range from outpatient mental
health clinics that provide only ambulatory services to psychiatric hospitals
(either public or private) that provide inpatient care. In between, the forms of
organizations cover the entire spectrum. They include residential treatment
centers for children with serious emotional disturbance, mental health
organizations that offer only day or night partial care, multiservice mental
health organizations that may include organizational forms such as community
mental health centers, and finally, general hospitals that offer separate
psychiatric services. Also, services may be provided by facilities operated by
the Department of Veterans Affairs or other Federal agencies.

Over the period 1970-1990, the characteristics
of the mental health system changed dramatically in the number, capacity,
structure, and operation of organizations that provide service. As an example,
during this period, the total number of mental health organizations increased
steadily with almost all of the increase occurring in the number of private
psychiatric hospitals, separate psychiatric services of general hospitals, and
residential treatment centers for children with serious emotional disturbance.
By contrast, the number of state and county mental hospitals and freestanding
psychiatric outpatient clinics decreased.

In addition to these types of organizational
forms, mental health services may also be provided to individuals through
various managed care organizations. These organizational forms emerged in the
1970s and developed largely in the private sector primarily serving the employed
population.

The health maintenance organization (HMO),
the most familiar type of managed care organization, provides mental health
services through a variety of approaches including the direct provision of
mental health services through internal, formal departments as well as through a
variety of external mechanisms such as referral agreements and contractual
arrangements with private providers, specialized managed mental health care
organizations, and arrangements with community agencies. Beginning in the late
1980s, the types of managed care organizations began to proliferate. As the
forms began to change so too did the contracting arrangements and other
mechanisms within these organizations for providing mental health services.

In the late 1980s and early 1990s, managed care
organizations began contracting with states to provide mental health services to
Medicaid beneficiaries. These arrangements can assume a variety of forms. For
example, a state may choose to integrate mental health services into
comprehensive systems of care or it may separate these services from the rest of
health care benefits. Debate continues about the optimal way to design these
approaches and about which approach will best meet the mental health needs of
the Medicaid population.

How is access to care
measured? Early findings reported in 1995 by
Berk, Schur,
and Cantor from the National Access to Care Survey sponsored by The Robert Wood
Johnson Foundation (RWJF) suggest that 1.4 percent of those surveyed reported
that they were unable to obtain mental health care. Although this is a
relatively low percent, it is much higher than reported in previous studies. The
RWJF investigators note that the estimate of 1.4 percent must be interpreted
with caution because it represents only those individuals who realize that they
require mental health services and who actively seek such services. The
catchment area studies that have been conducted indicate that a much larger
proportion of the population may require services but may not be receiving them.

Services research has attempted to focus on
differences in access to care across income levels, racial groups, age, etc.
Financial barriers, including the lack of insurance coverage, have been of
particular interest to service researchers. However, barriers to appropriate
care may also include sociocultural, organizational, as well as other
nonfinancial factors such as geographic availability.

In many of the studies conducted, however,
service utilization seems to be equated with access to care. That is, if service
use is low for a particular group, then the low utilization often seems to be
explained as an accessibility issue.

In reality, access to service may be more of an
underlying construct whose indicators may be concretely measured by the length
of waiting times, the difficulty in obtaining appointments, and the distance to
a service site. However, access to care also involves individual perceptions and
attitudes about such indicators. For example, for one individual, waiting for an
appointment for two weeks may seem reasonable whereas for a second individual,
two weeks may be perceived as inordinately long. For the second individual, the
waiting period may have become a barrier to receiving timely, appropriate care.

Access to mental health care is a multifaceted
issue that involves individual perceptions, demographic characteristics,
organizational practices, and delivery system attributes. While it may be true
that low levels of service utilization can be indicative of an access problem,
service utilization cannot be causally linked to access without further
analyses. What is troublesome is that, too often in the literature, the analyses
have stopped with an examination of levels of service use.

Who pays for mental health services? In Mental Health, United States, 1994,
Frank and McGuire identify and discuss three major categories of financing
arrangements for mental health services: Federal, State, and private insurance.
These particular categories were selected because they account for a large
proportion of mental health payments and because the responsibility for payment
varies among the three mechanisms.

Most individuals in the United States are
covered by private health insurance offered through their employers and this
arrangement represents the primary payment method for mental health services
(1991 data). Usually, individuals must pay a monthly premium in order to receive
employment-based health insurance. This insurance often imposes limits on both
inpatient and outpatient coverage. Although these limits may vary by employer,
typical limits include 30 days of inpatient care and 25 outpatient visits with
50 percent cost-sharing.

Historically, mental health care has been
subject to coverage restrictions in private health insurance for a variety of
reasons including its perceived ineffectiveness, the high levels of demand for
mental health care when compared to other medical conditions, the risk of
attracting more individuals who need services to plans that provide good
coverage for mental health services, and the fact that the public, in general,
seems to hold unfavorable stereotypes about mental illness and about those
individuals who suffer from mental disorders.

Although subject to Federal mandates and
oversight, Medicaid, the second type of financing system, is a State-run program
financed through a combination of Federal and State contributions. The program
varies widely by State in terms of benefit design and payment system provisions.

With respect to the coverage of mental health
services, states may define particular services that will be paid for within
general, broader categories of services. Therefore, services required to treat
mental illness may not be covered even if services for other conditions are.
Moreover, states may specify the amount and duration of each of the services and
mental health treatment services may have different limits in the number of
visits, periods of coverage, reimbursement amounts, and types of providers.

Recently, it has been argued that the Medicaid
system of care for individuals with severe mental disorders was fragmented and,
as a result, individuals could actually be harmed because many fail to receive
needed services or they receive inappropriate services. To rectify this
situation, a growing number of states began, in 1986, to reimburse mental health
providers to manage the services required by these individuals. Currently, the
majority of states pay for this type of service coordination.

The third type of financing system involves
State governments primarily through State mental health agencies. As might be
expected, the responsibilities and programs of State mental health agencies vary
widely across the States. These agencies may be responsible for various types of
services ranging from children's mental health to domestic violence services.
The delivery of services may be provided through central Statewide organizations
or may be controlled by local authorities.

With respect to expenditures, in 1990, 58
percent of the funds controlled by State mental health authorities were used for
services provided by State mental hospitals while 38 percent went to programs
operated in the community; in 1981, the proportions were 67 percent and 29
percent, respectively. Since 1981 the trend toward more community-based care has
accentuated the role played by the more local levels of government such as city,
county, or catchment area authorities.

Beginning in the early 1990s, states began to
rely increasingly on privately owned providers (such as HMOs or subcontracted
specialized firms) to manage mental health services in the public system. While
it is too early to assess the impact of managed mental health care in the public
system, early data suggest that problems in implementation and funding often
slow the development and growth of managed care in this sector.

How should we think about quality?From the mid-1960s to the mid-1980s, studies
that focused on quality of care were conducted by hospital accreditation and
peer review committees. The classic conceptual framework used to examine quality
of care involved the use of structural, process, and outcome measures.

Using this classic framework, two broad
categories of studies were conducted and reported during the early 1970s and
into the 1980s. The first category described peer review programs in various
types of settings, e.g., hospitals, community mental health centers, and
state/national professional associations. Critics of these peer review programs
complained that in many cases investigators failed to employ external,
predetermined standards. The second type of study addressed the appropriateness
of psychotropic medication prescribing practices. Critics of this type of study
argued that appropriateness was evaluated largely by relying on implicit rather
than explicit criteria.

Beginning in the late 1980s, quality of care
studies were incorporated into services and policy research for two primary
reasons. First, emerging reimbursement strategies, e.g., prospective payment,
raised issues about quality of care. For example, if these strategies encouraged
clinicians to limit the quantity of care, what would the impact be on the
quality of care? Second, several studies in the late 1970s and early 1980s
documented variations in the cost, process, and outcomes of care across
hospitals and providers.

Services researchers tend to examine two major
aspects of the delivery process: technical process (the amount, type, and the
way in which resources are used) and art of care (the interaction between the
provider of care and the individual who seeks care). Each of these aspects can
be examined in a variety of ways depending upon the disciplinary training of the
investigator.

Several important types of this kind of research
can be identified. First, governmental agencies, insurers, as well as employers,
are interested in whether the outcomes achieved justify the expenditures. This
is referred to as the cost-quality trade-off issue and can be conceptualized in
the following manner: Initially, using more resources will probably result in
higher levels of quality, but after a period of time, using additional resources
will not increase the quality of care provided. Finally, at some point, using
more resources (and increasing expenditures) may actually negatively affect the
quality of care provided. Second, researchers examine the impact on the health
and functional status of individuals when aspects of the delivery system change
so that the individual's ability to obtain needed care is altered. Finally, a
developing body of literature addresses the extent to which interventions are
used appropriately. In the research on psychotherapy, clinical researchers in
psychology have begun to assess, both through meta-analytic reviews of the
literature and by clinically based investigations, which interventions are
efficacious for particular disorders.

In the late 1980s and 1990s, various
organizations, e.g., the American Psychological Association, the American
Psychiatric Association, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), became actively involved in shaping both the guidelines
used to assess the quality of care and the evaluation process itself.

In summary, for three decades, research on
defining, measuring, and examining various aspects of quality has occurred and,
as a result of these efforts, the field of mental health services research has
made great strides. However, to continue the progress, the field requires 1)
more data on the variation within clinical practice, 2) the adoption of a
variety of techniques by which studies may be designed and complex data analyzed
and, 3) a greater degree of collaboration among researchers from the various
fields and disciplines.

What is outcome-based
evaluation? The evaluation of programs and services began in
the 1960s after the number of social programs grew and requests for evaluations
of them emanated from both funding sources and governmental bodies/agencies. The
purpose of evaluation is to inform decisionmakers, outline available options,
and to provide feedback about programs or services. Recently a growing number of
evaluation theorists have argued that evaluation projects are able to produce
more useful information when they are grounded in a theoretical framework.
Theories that guide evaluation projects may focus on the selection of an
intervention, the intervention process itself, and/or the underlying theory or
theories of the disorder under investigation.

The growth of managed systems of mental health
care triggered a shift in the way in which evaluation is conceptualized and in
the techniques that are used. In the world of managed care, evaluation became
outcome-based. The vague question, Is the individual doing better?, is no longer
acceptable. More precise questions such as, Does treatment work in ways that are
measurably valuable to the individual, the payor of services, the clinician, and
to the managed care organization?, must be answered. However, it must be
emphasized that, in the mid 1990s, outcomes research in the mental health field
is still in its infancy.

In general though, in 1995, McLellan and Durell
note that there are several pragmatic guiding principles that should be followed
when outcome-based evaluations are designed and conducted. First, it is
necessary to assess an individual before the actual program or treatment begins
as well as after the course of care has terminated. Second, the outcomes to be
examined must include indicators of health, adaptive behavior, and role-specific
social functioning and should not be limited simply to the diagnostic categories
of illness. Third, whenever possible, outcome evaluations should employ
standardized measures that are appropriate for the specific group being studied.
Fourth, in follow-up contacts with individuals who have completed a program, the
contact rate must be relatively high (above 70%) for the results to be valid.
Finally, an assessment of change and outcome status offer differing
perspectives, therefore, both a measurement of change in function from pre- to
post- intervention as well as an assessment of actual functional status must be
part of the evaluation.

The World Health Organization proposed a mental
health outcomes framework that includes five broad elements and the major types
of outcomes to be examined:

Physical Health includes general health as
well as the physiological effects produced by intervention. Outcomes focus on
physical symptoms, mortality, medication side effects, and physical development
and health.

&nbsp:

Psychological Health includes well-being, self-esteem,
affective states, and sensory and cognitive functioning. Outcomes encompass
measures of psychological and cognitive development, symptoms and side effects,
level of distress, and sense of well-being;

&nbsp:

Level of Independence
encompasses
activities of daily living, capacity for communication, work, adaptive growth,
and dependence on substances. Outcomes may include performance in work and
school, reliance upon restrictive services, independent living, level of
impairment from substance use, and criminal activity;

&nbsp:

Social Relationships
involve intimacy and loving relationships as well as the participation in giving
and receiving social support. Outcomes encompass measures of the presence and
strength of social supports, relationships with peers, family functioning, and
parenting ability; and,

&nbsp:

Environmental
domain includes an
examination of both the community and residential environment as well as safety
issues, material resources, and the availability of adequate services. Outcomes
include the adequacy and stability of housing and income as well as the level of
protection from victimization.

In 1995, Schalock offers three broad types of
outcome-based analyses that can be conducted depending upon the purpose of the
evaluation and the availability of information or data.

Effectiveness
Analysis. This type of analysis addresses the question of whether the
program or intervention met the intended goals and objectives. Its major
purposes include describing results, establishing a feedback mechanism, and
offering information that facilitates program/treatment change.

Impact Analysis.
This type of analysis determines whether the program or intervention made a
difference compared to either no intervention or an alternative intervention. An
absolute requirement is that a comparison group or condition be present. The
purpose of this type of analysis is to focus on the impacts of the intervention,
determine whether the impacts can be attributed with reasonable certainty to the
intervention or service being evaluated, and to provide feedback. This type of
analysis includes controlled clinical trials.

Cost-Benefit Analysis.
The primary issue addressed by cost-benefit analysis is whether the impacts of
the program are large enough to justify the costs needed to produce them. It
relies heavily upon the clear delineation and measurement of impacts and the
costs involved in generating them.

The research on mental health outcomes is
difficult to summarize effectively since much of the work focuses on particular
groups with specific disorders, e.g., outcomes of juvenile-onset depression,
particular drug therapies for specific disorders, e.g., relapse of individuals
with mood disorders who are taking lithium, or on the use of particular
treatment modalities or treatment settings, e.g., community-based treatment vs.
inpatient treatment. The annual Faulkner & Gray Behavioral Outcomes &
Guidelines Sourcebooks provide an extensive review of the literature and include
state-of-the-art approaches to outcomes research.

Children.
Although concern about children and adolescents with serious emotional
disturbance has existed for over ten years, it recently has emerged as a
critical issue in mental health policy. There are two broad areas in which
advances have been made. First, progress has been made in developing instruments
for assessing emotional disturbance in children. Second, it has been possible to
determine treatment efficacy for specific mental disorders. However, in Mental
Health, United States, 1994, Hoagwood and Rupp note that the extent of
emotional disturbance among children, the actual but unmet need for care, the
types of services utilized, and the ways in which children enter the mental
health system are issues that will require additional research.

The reasons for such gaps in our collective
knowledge about children's mental health needs and service patterns are
numerous. For example, the way in which serious emotional or behavioral
disturbances are defined with respect to children vary by profession, Federal
agencies and States. As might be predicted, these variations confound any
attempt to coordinate care across the different levels of government.

In addition, the responsibility for children's
mental health services is dispersed across many service systems including
education, welfare, the justice system, etc. Children with mental health needs
are scattered across these systems and the needs of the children do not
necessarily coincide with the system that provides the service, e.g., children
with learning difficulties are not necessarily treated for learning difficulties
in the educational system.

Despite the somewhat bleak picture presented,
changes are occurring and research efforts are underway under the auspices of
the National Institute of Mental Health to answer several important questions
such as: What is the extent of unmet need for services by children and their
families? What are the barriers to obtaining these services? What are the costs
of care across program elements in the various service sectors? How are mental
health services for children and adolescents financed? And, what impact will
managed mental health systems of care have on the delivery of services to
children?

The
Elderly. In general, older adults are more likely to use inpatient than
outpatient services, are more likely to use general hospitals than other
treatment sites, and are likely to be treated by general medical practitioners
rather than by mental health professionals. In addition, the underutilization of
mental health services by the elderly has been documented and attributed to a
number of factors including: reluctance to seek treatment because of the stigma
attached to mental illness, inadequate detection of mental disorders among the
elderly by clinicians, relatively low referral rates by general practitioners,
and limited knowledge on the part of the elderly regarding the availability of
mental health services.

In 1995, Estes identifies a lengthy research
agenda for the future. The structure and performance of mental health delivery
affects access, cost, and quality and studies that examine these relationships
must be conducted. More information is needed about the extent to which the
elderly are served by varying types of organizations, e.g., for-profit,
not-for-profit, or public, and about the effects of various financing
mechanisms, e.g., capitation, on service use and access to care. Further
research is required on the types of interorganizational relationships that are
forming between local mental health providers and other types of providers of
services to the elderly.

The number of elderly is predicted to increase
in the next two decades and the demand for services by this group will more than
likely increase as well. Very little is known about the effects of mental health
policy on the elderly, therefore, this area must be one that receives special
attention in the future.

Ethnic
Minorities. In 1996, Takeuchi and Uehara review the existing research and
suggest the areas that will require more attention from researchers in the
future. They note that although the details may vary across ethnic groups, in
general, the research indicates that the mental health needs of ethnic
minorities are largely unmet. In addition, when services are available, they
are, more often than not, inappropriate.

Assessing the prevalence of mental disorders and
the need for services among ethnic minority groups has proved to be problematic.
Treatment data have often been employed in an attempt to estimate the prevalence
and need for service. Early studies seemed to indicate that African Americans
have been overrepresented and Asian Americans underrepresented in mental
hospitals. The evidence for Latino Americans remains ambivalent. It is important
to point out that most epidemiologists believe that service use is an unreliable
indicator of actual need and this may be particularly true for ethnic minority
groups because many members of these groups have difficulty accessing and using
services as they are currently designed.

Although methodological problems hamper the
generalizability of community studies that have been conducted on the extent of
mental health problems in ethnic minority populations, two general points can be
made. First, several of the community studies contradict the evidence derived
from treatment data. For example, about one half of the community studies
conducted in recent years have demonstrated that African Americans had a higher
rate of psychopathology (supporting the conclusions that were drawn from
treatment studies); however the other half of the studies conducted reported
that the rate of psychopathology was comparable or even lower than that found in
White Americans.

Second, there seems to be controversy
surrounding the issue of whether the differences in prevalence rates should be
attributed to ethnic minority status or social class phenomena. Two theoretical
frameworks are employed in an attempt to explain the ethnic minority-White
American differences in psychological distress and psychopathology. The first
framework suggests that forms of psychopathology and distress, in general,
derive from the fact that society tends to stratify individuals according to
their ethnic and racial backgrounds thereby creating serious obstacles to
equality in economic, occupational, and educational opportunities. The second
framework argues that race differences in psychopathology disappear when social
class is taken into account in the study design. This framework suggests that
barriers created by lower incomes, not ethnicity per se, can result in
debilitating effects on individuals or groups.

Finally, a number of empirical studies suggested
that ethnic minorities do not seek professional treatment for mental health
issues as often as other groups do. Moreover, when ethnic minorities use mental
health services, treatment tends to be inappropriate or inadequate. Minority
service providers and researchers have suggested that the mental health system
must become more sensitive and responsive to the needs of ethnic minorities.
However, few studies have described what such sensitivity entails or identified
what factors might contribute to a more effective mental health system.

Persons
with Severe Mental Illness. In 1989, the National Institute of Mental Health
in collaboration with the National Center for Health Statistics provided
supplementary information to the National Health Interview Survey. The purpose
of the project was to update the estimates of the number of persons with severe
mental illness in the household population of the United States and to examine
the use of various mental health services.

The survey findings suggest that the number of
persons with severe mental illness can be conservatively estimated to include
2.1 to 2.6 percent of the adult population. This estimate has various components
including individuals living in households, nursing homes, mental hospitals,
State prisons, and individuals who are homeless.

A 1991 report, Caring for People With Severe
Mental Disorders: A National Plan of Research to Improve Services, prepared
by the National Advisory Mental Health Council offered recommendations for
research designed to improve the quality of care for individuals suffering from
severe mental disorders. However, even if knowledge from this line of research
was available, issues of providing such services in an efficient, economical,
and equitable manner would still exist.

The dilemma of how to develop effective service
systems for persons with severe mental illness as well as persons with both
severe mental and substance abuse disorders (dual diagnoses) will continue to
confront providers of service, planners, and service researchers. The National
Advisory Mental Health Council's report identifies crucial areas that will
require the attention of mental health service researchers in the future. For
example, given the number of agencies, eligibility criteria, and recertification
requirements that exist for programs attempting to serve these groups, what are
the optimal organizational and procedural arrangements for providing health
insurance coverage, housing, income maintenance, and rehabilitation? In many
parts of the country adequate resources are simply unavailable. Moreover, the
delivery system, as it exists, may not have adequate staffing levels or
financing arrangements. As the report indicates, research that addresses the
development and evaluation of strategies for improved community and State
systems of care for individuals with severe mental illness must be given
priority.

Persons with Mental Illnesses Who Have Been
Arrested. The number of persons who are
incarcerated and who exhibit mental disorders is increasing. Those persons with
mental disorders who have been arrested for serious offenses should, it has been
argued, remain in jail but receive mental health treatment while incarcerated.
How best to provide the needed array of services both while the individual is in
jail and especially after the individual is released remains controversial.

It has also been argued that individuals with
mental disorders who have been arrested for nonviolent crimes may benefit more
from diversion programs than from incarceration. Although these programs
begin to address the issue of the growing number of persons with severe mental
disorder who are incarcerated for minor offenses, in general, the literature
offers little assistance with respect to definitions or guiding principles for
developing effective programs. Additional longitudinal studies are required
using client-based and organizational outcome measures.

Cost-sharing: Methods, such as
deductibles and coinsurance, that are employed to spread the cost of a program
among interested parties and/or to contain the costs of a program.

Deinstitutionalization: A movement that
began in the mid-1950s and continued through the mid-1970s whose goal was to
shift individuals suffering from mental disorders out of the state hospitals and
into community-based treatment settings.

Diversion Programs: Mechanisms and
personnel used to 1) screen and evaluate individuals for mental health disorders
while they are detained in jail; 2) negotiate with other agents within the legal
and mental health system to produce a disposition that facilitates treatment
rather than mere detention; and, 3) link detainees with follow-up services in
the community.

Health Maintenance Organization (HMO):
As originally conceived in 1971, this type of organization offered health care
services using five key features that differed from the traditional
fee-for-service practice: 1) Contractual responsibility was built in to provide
or assure the delivery of a stated range of health services; 2) The population
to be served was defined by enrollment in a specific plan; 3) Enrollment was
voluntary; 4) The enrollee or consumer paid a fixed annual or monthly payment
that was independent of the services used; and, 5) The organization assumed at
least part of the financial risk or gain in the provision of services.

Managed Care: This is a generic term
for organized systems of care that include precertification requirements, a
limited network of providers, and risk-based payment.

Offset Effects: Mental health services
that, when used, reduce costs in other service areas provided by the insurance
plan.

Outcome: Changes in adaptive behavior(s)
and role status that are logical consequences of mental health services.

Quality of Care: The degree to which
mental health services for individuals and populations increase the likelihood
of desired mental health outcomes and which are consistent with current
professional knowledge.

National Advisory Mental Health
Council. (1991). Caring for People With Severe Mental Disorders: A
National Plan of Research to Improve Services. Supt. of Docs., U.S.
Govt. Print. Off.: Washington, D.C.